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Implantable Cardioverter-Defibrillators (ICD)

Our Approach for ICD

The most dangerous arrhythmias are ventricular fibrillation and ventricular tachycardia, which may cause cardiac arrest and cessation of blood flow. Implantable cardioverter-defibrillators (ICDs are the most effective treatment to significantly improve survival of these patients.

At Stanford, our electrophysiologists have extensive expertise in using ICDs to treat people with arrhythmia and other electrical problems within the heart. ICDs use electrical shocks or pulses to regulate the heartbeat.

What is an Implantable Cardioverter-Defibrillator?

About ICD

An ICD is a small, battery-powered device that our heart specialists implant under the skin in your chest or abdomen. At Stanford, we use ICDs to treat arrhythmias in which the heart beats too fast, especially two dangerous types:

How an ICD Works

ICD can treat ventricular tachycardia in two ways. In some cases, the ICD stops the abnormal heartbeat by rapidly sending small electrical pulses to your heart. This signal is usually painless. In other cases, the ICD delivers a large amount of energy to shock the heart back to a normal rhythm. This shock may feel like a jolt to your chest.

ICD Components

The device has four main parts:

A pulse generator, a tiny computer that produces electrical signals to regulate heartbeat

One or two leads, wires that deliver electrical signals between the pulse generator and the heart

Electrodes at the ends of the leads, to help deliver the signals, or energy

A battery

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What to Expect

At Stanford, we use ICDs to treat arrhythmias in which the heart beats too fast. Learn more about what to expect with ICD with the following information:

Before

During

After

At Home

Before the Procedure

The doctor or an advanced practice provider will explain the procedure and offer the opportunity to ask any questions about the procedure.

Patients will not be able to eat or drink for eight hours prior to surgery.

If patient is pregnant or suspects pregnancy, patient should notify the doctor.

Please make the doctor aware of the following items:

Sensitivities or allergies for any medications, iodine, latex, tape, or anesthetic agents (local and general)

All current medications (prescription and over-the-counter) and herbal supplements

A history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting

It may be necessary for you to stop some of these medications prior to the procedure. The doctor or care team member will discuss this prior to scheduling the procedure

The doctor may request a blood test prior to the procedure to determine how long it takes for the blood to clot. Other blood tests may be done as well.

The upper chest may be clipped prior to the procedure.

A special wash kit will be given to be used the day before and the day of the procedure.

Based upon the medical condition, the doctor may request other specific preparation.

During the Procedure

Implantation of the Device

The procedure is performed in the cardiac catheterization laboratory. The patient may be given either sedation or general anesthesia. If general anesthesia is used, patients will be placed under the care of an anesthesiologist who will give medication to help with relaxation during the procedure. A local anesthetic will be given at the site of the ICD implant, usually beneath the collar bone on the left side of the upper chest.

After the area is numb, the doctor will create a "pocket" or space for the generator. Access to the vein under the collar bone is obtained and one or more leads (thin wire-like tubes) are advanced to the heart. The lead system will be placed in your heart, through a vein in your upper chest and guided into position with the assistance of fluoroscopy (X-ray).

Once the lead is secured in place, it is attached to the generator. While patient is asleep, the device is programmed and tested.

The incision will then be sutured and a dressing will be placed over it. The entire procedure will last 3-4 hours.

Generally, an ICD insertion follows this process:

Patients will be asked to remove any jewelry or other objects that may interfere with the procedure

Patients will be asked to remove clothing and will be given a gown to wear

Patients will be asked to empty their bladder prior to the procedure

An intravenous (IV) line will be started in the hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed

Patients will be placed in a supine (on the back) position on the procedure table

Patients will be connected to an electrocardiogram (ECG or EKG) monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure

Large electrode pads will be placed on the front and back of the chest

Patients will receive a sedative medication in the IV before the procedure to help patients relax. However, patients will likely remain awake during the procedure

The ICD insertion site will be cleansed with antiseptic soap

Sterile towels and a sheet will be placed around this area

A local anesthetic will be injected into the skin at the insertion site

Once the anesthetic has taken effect, the doctor will make a small incision at the insertion site

A sheath, or introducer, is inserted into a blood vessel, usually under the collarbone. The sheath is a plastic tube through which the ICD lead wire will be inserted into the blood vessel and advanced into the heart

It will be very important for patients to remain still during the procedure so that the catheter placement will not be disturbed and to prevent damage to the insertion site

The lead wire will be inserted through the introducer into the blood vessel. The doctor will advance the lead wire through the blood vessel into the heart

Once the lead wire is inside the heart, it will be tested to verify proper location and that it works. There may be one, two, or three lead wires inserted, depending on the type of device the doctor has chosen for the condition. Fluoroscopy, a special type of x-ray that will be displayed on a TV monitor, may be used to assist in testing the location of the leads

Once the lead wire has been tested, an incision will be made close to the location of the catheter insertion (just under the collarbone). Patients will receive local anesthetic medication before the incision is made

The ICD generator will be slipped under the skin through the incision after the lead wire is attached to the generator. Generally, the generator will be placed on the non-dominant side. (If patients are right-handed, the device will be placed in the upper left chest. If patients are left-handed, the device will be placed in the upper right chest)

The ECG will be observed to ensure that the pacer is working correctly.

The skin incision will be closed with sutures, adhesive strips, or a special glue

A sterile bandage/dressing will be applied

After the Procedure

After the procedure, patients will be admitted to a monitored unit for overnight observation. A nurse will monitor vital signs for a specified period. Patients will be instructed not to move the arm on the side of the implant. This gives the lead time to stabilize in the vein and heart. If patients feel soreness after this procedure, notify the nurse who will give you medication to make you more comfortable.

Patients should immediately notify the nurse if they feel any chest pain or tightness, or any other pain at the incision site.

After the specified period of bed rest has been completed, patients may get out of bed. The nurse will assist patients the first time they get up, and will check their blood pressure while lying in bed, sitting, and standing. Patients should move slowly when getting up from the bed to avoid any dizziness from the period of bedrest.

Patients will be able to eat or drink once completely awake. The insertion site may be sore or painful, but pain medication may be administered if needed.

The doctor will visit with patients in their room while recovering. The doctor will give specific instructions and answer any questions.

Once blood pressure, pulse, and breathing are stable and patients are alert, they will be taken to their hospital room or discharged home. Patients are reassured that the defibrillator will not harm others even if it should fire while the patient is touching someone else. Patients should arrange to have someone drive home from the hospital following the procedure.

At Home

Patients must do several things to care for themselves after leaving the hospital. Antibiotics are sometimes prescribed and may need to be taken for a full five day course. Check temperature twice daily to determine if it is elevated (possibly indicating an infection).

Patients will most likely be able to resume their usual diet, unless the doctor instructs differently.

Ask the doctor about returning to work. Occupation, overall health status, and progress will determine how soon patients may return to work.

It will be important to keep the insertion site clean and dry. The doctor will give specific bathing instructions.

The doctor may give additional or alternate instructions after the procedure, depending on the patient’s needs.

Wound Care

Patients are instructed not to lift the elbow that is on the side of the defibrillator above the ear for 4 weeks after implantation. Movement of the large shoulder muscle could cause the lead inside of the heart to move out of position. Patients may be instructed not to lift the arms above the head for a period.

Patients are instructed not to participate in any activities that require forceful large arm movements, such as basketball, swimming, and golf, for 4 weeks following surgery. Patients should discuss questions about exercise with their Arrhythmia Team.

Driving should be discussed on an individual basis with the patient's doctor. Patients with an ICD should not drive until the doctor gives approval. The doctor will explain these limitations, if they are applicable to the patient’s situation.

Patients are instructed to avoid sitting in the sun without covering the generator site because it may become excessively warm beneath the skin.

Patients should slowly increase activity over several days. The doctor will tell patients if they will need to take more time in returning to your normal activities. Avoid heavy lifting, and activities that involve rough contact with the area where the pulse generator and leads are located.

Activity

Activity on the side of the ICD should be limited for 4-6 weeks (6 weeks recommended for Biventricular ICD) as follows:

Do not lift the elbow that is on the side of your ICD above the shoulder. Movement of the large shoulder muscle could cause the lead inside of the heart to move out of position. Repositioning of the leads will require a surgical procedure

Do not participate in any activities that require forceful large arm movements, such as basketball, swimming, golf, and vacuuming

Do not lift anything over 10 pounds

We recommend walking for at least 30 minutes, five days a week. You may increase your activities slowly and resume your usual level of activity after 6 weeks

If you have additional questions about activities and exercise, please discuss them with your Stanford care team

Driving should be discussed on an individual basis with your doctor.

Cover the ICD site if in direct sunlight as the metal of the ICD will warm beneath the skin.

Magnetic Interference

Electromagnetic fields can interfere with the ICD’s ability to sense an abnormal rhythm. Some devices and machines are safe to use while other devices are not:

Avoid devices or areas that have strong electric or magnetic fields such as: leaning over a car engine while it is running, running motorcycle engines, power plants, ham radios, etc.

Cellular phones, MP3 players, and headphones should be held at least 6 inches away from your ICD. Hold the phone on the ear opposite your ICD and avoid keeping your phone and headphones in a pocket on top of your ICD. Avoid resting your head on the chest of a person with an ICD while wearing headphones.

When traveling in the airport, tell security you have an ICD and request for a hand search instead of walking through the metal detector. The metal detector will not harm the ICD but it may set off the alarm. Limit scanning with a hand-held metal detector over the device no longer than necessary.

Inform your health care provider, such as your dentist, that you have an ICD before they perform any test or procedure using medical or electronic devices:

If you are to undergo dental procedures or any type of surgery involving electrocautery, have your dentist/doctor contact either the device manufacturer or Cardiac Arrhythmia Service. The electrocautery might be misinterpreted by the ICD as an arrhythmia and deliver a shock or therapy that you do not need.

Normal teeth cleaning are safe and require no special instructions.

Important: You cannot have an MRI done because of the possible magnetic interference.

Identification

Carry your ICD identification card in your wallet at all times. You will be given a temporary card upon discharge. A permanent card will be mailed to you from the ICD manufacturer in 6-8 weeks.

We suggest that you wear a Medic Alert Emblem. Please ask for the form if you have not been given one.

Please notify your ICD manufacturer if you have a new address or telephone number. Their toll-free phone number is on the temporary and permanent identification card.

Symptoms

If you feel any of the following symptoms, you should lie down immediately, make sure you are in a safe environment, away from any machines or moving vehicles, and call a friend or family member, or call 911:

Lightheadedness

Fast heart rate (palpitations)

Dizziness

Chest pain

Shortness of breath

Fainting or near fainting (syncope)

What To Do If Your Feel a Shock

Call 911 immediately for the following:

If you receive 1-2 shock but you still do not feel well

If you receive 3 or more shocks in rapid succession

If you receive a shock but become or remain unconscious, bystanders should call 911 and immediately start CPR

Call the Stanford Arrhythmia Service at (650) 723-7111 for the following:

If you receive 1-2 shocks and feel that your heart rhythm is back to normal. This is not an emergency if you feel okay but it is important to inform us immediately after the shock

If you did not have any symptoms of an arrhythmia but received a shock, we will set up an appointment to confirm appropriateness of your ICD therapy

If you receive a shock from the ICD while in contact with another person, it will not harm them

Discuss a plan with your family members and friends on what should be done if you receive a shock from your ICD (also called a “shock plan”)

It is advisable that family members be certified in CPR. Classes are available at local chapters of the American Heart Association or the Red Cross.

Follow-Up

At discharge, you will be given a clinic appointment for a wound check at Stanford within 10 to 14 days after implant. Please contact the Stanford Device Clinic at (650) 723-6459 if an appointment for a wound check prior to discharge has not been arranged for you.

It is very important that you have your ICD checked regularly (4 to 6 weeks after implant and every 3 to 4 months thereafter).

It is recommended that you know your ICD parameters. We will give you a copy of your ICD parameters and answer any questions that you may have regarding your device programming upon discharge or during your first clinic visit for a wound check or device check.

Some devices are equipped with Remote Monitoring capabilities where you can send information about your ICD from home that the clinic can view. We recommend that you have this capability for your routine device surveillance. We will discuss with you at your clinic visit.

The device clinic will hold a quarterly patient education seminar regarding general information about ICDs. We will give you the opportunity to ask specific questions regarding your device and to interact with other patients with ICD. Please ask us for the seminar schedule.

Important Phone Numbers

Before the Procedure

The doctor or an advanced practice provider will explain the procedure and offer the opportunity to ask any questions about the procedure.

Patients will not be able to eat or drink for eight hours prior to surgery.

If patient is pregnant or suspects pregnancy, patient should notify the doctor.

Please make the doctor aware of the following items:

Sensitivities or allergies for any medications, iodine, latex, tape, or anesthetic agents (local and general)

All current medications (prescription and over-the-counter) and herbal supplements

A history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting

It may be necessary for you to stop some of these medications prior to the procedure. The doctor or care team member will discuss this prior to scheduling the procedure

The doctor may request a blood test prior to the procedure to determine how long it takes for the blood to clot. Other blood tests may be done as well.

The upper chest may be clipped prior to the procedure.

A special wash kit will be given to be used the day before and the day of the procedure.

Based upon the medical condition, the doctor may request other specific preparation.

close Before

During

During the Procedure

Implantation of the Device

The procedure is performed in the cardiac catheterization laboratory. The patient may be given either sedation or general anesthesia. If general anesthesia is used, patients will be placed under the care of an anesthesiologist who will give medication to help with relaxation during the procedure. A local anesthetic will be given at the site of the ICD implant, usually beneath the collar bone on the left side of the upper chest.

After the area is numb, the doctor will create a "pocket" or space for the generator. Access to the vein under the collar bone is obtained and one or more leads (thin wire-like tubes) are advanced to the heart. The lead system will be placed in your heart, through a vein in your upper chest and guided into position with the assistance of fluoroscopy (X-ray).

Once the lead is secured in place, it is attached to the generator. While patient is asleep, the device is programmed and tested.

The incision will then be sutured and a dressing will be placed over it. The entire procedure will last 3-4 hours.

Generally, an ICD insertion follows this process:

Patients will be asked to remove any jewelry or other objects that may interfere with the procedure

Patients will be asked to remove clothing and will be given a gown to wear

Patients will be asked to empty their bladder prior to the procedure

An intravenous (IV) line will be started in the hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed

Patients will be placed in a supine (on the back) position on the procedure table

Patients will be connected to an electrocardiogram (ECG or EKG) monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure

Large electrode pads will be placed on the front and back of the chest

Patients will receive a sedative medication in the IV before the procedure to help patients relax. However, patients will likely remain awake during the procedure

The ICD insertion site will be cleansed with antiseptic soap

Sterile towels and a sheet will be placed around this area

A local anesthetic will be injected into the skin at the insertion site

Once the anesthetic has taken effect, the doctor will make a small incision at the insertion site

A sheath, or introducer, is inserted into a blood vessel, usually under the collarbone. The sheath is a plastic tube through which the ICD lead wire will be inserted into the blood vessel and advanced into the heart

It will be very important for patients to remain still during the procedure so that the catheter placement will not be disturbed and to prevent damage to the insertion site

The lead wire will be inserted through the introducer into the blood vessel. The doctor will advance the lead wire through the blood vessel into the heart

Once the lead wire is inside the heart, it will be tested to verify proper location and that it works. There may be one, two, or three lead wires inserted, depending on the type of device the doctor has chosen for the condition. Fluoroscopy, a special type of x-ray that will be displayed on a TV monitor, may be used to assist in testing the location of the leads

Once the lead wire has been tested, an incision will be made close to the location of the catheter insertion (just under the collarbone). Patients will receive local anesthetic medication before the incision is made

The ICD generator will be slipped under the skin through the incision after the lead wire is attached to the generator. Generally, the generator will be placed on the non-dominant side. (If patients are right-handed, the device will be placed in the upper left chest. If patients are left-handed, the device will be placed in the upper right chest)

The ECG will be observed to ensure that the pacer is working correctly.

The skin incision will be closed with sutures, adhesive strips, or a special glue

A sterile bandage/dressing will be applied

close During

After

After the Procedure

After the procedure, patients will be admitted to a monitored unit for overnight observation. A nurse will monitor vital signs for a specified period. Patients will be instructed not to move the arm on the side of the implant. This gives the lead time to stabilize in the vein and heart. If patients feel soreness after this procedure, notify the nurse who will give you medication to make you more comfortable.

Patients should immediately notify the nurse if they feel any chest pain or tightness, or any other pain at the incision site.

After the specified period of bed rest has been completed, patients may get out of bed. The nurse will assist patients the first time they get up, and will check their blood pressure while lying in bed, sitting, and standing. Patients should move slowly when getting up from the bed to avoid any dizziness from the period of bedrest.

Patients will be able to eat or drink once completely awake. The insertion site may be sore or painful, but pain medication may be administered if needed.

The doctor will visit with patients in their room while recovering. The doctor will give specific instructions and answer any questions.

Once blood pressure, pulse, and breathing are stable and patients are alert, they will be taken to their hospital room or discharged home. Patients are reassured that the defibrillator will not harm others even if it should fire while the patient is touching someone else. Patients should arrange to have someone drive home from the hospital following the procedure.

close After

At Home

At Home

Patients must do several things to care for themselves after leaving the hospital. Antibiotics are sometimes prescribed and may need to be taken for a full five day course. Check temperature twice daily to determine if it is elevated (possibly indicating an infection).

Patients will most likely be able to resume their usual diet, unless the doctor instructs differently.

Ask the doctor about returning to work. Occupation, overall health status, and progress will determine how soon patients may return to work.

It will be important to keep the insertion site clean and dry. The doctor will give specific bathing instructions.

The doctor may give additional or alternate instructions after the procedure, depending on the patient’s needs.

Wound Care

Patients are instructed not to lift the elbow that is on the side of the defibrillator above the ear for 4 weeks after implantation. Movement of the large shoulder muscle could cause the lead inside of the heart to move out of position. Patients may be instructed not to lift the arms above the head for a period.

Patients are instructed not to participate in any activities that require forceful large arm movements, such as basketball, swimming, and golf, for 4 weeks following surgery. Patients should discuss questions about exercise with their Arrhythmia Team.

Driving should be discussed on an individual basis with the patient's doctor. Patients with an ICD should not drive until the doctor gives approval. The doctor will explain these limitations, if they are applicable to the patient’s situation.

Patients are instructed to avoid sitting in the sun without covering the generator site because it may become excessively warm beneath the skin.

Patients should slowly increase activity over several days. The doctor will tell patients if they will need to take more time in returning to your normal activities. Avoid heavy lifting, and activities that involve rough contact with the area where the pulse generator and leads are located.

Activity

Activity on the side of the ICD should be limited for 4-6 weeks (6 weeks recommended for Biventricular ICD) as follows:

Do not lift the elbow that is on the side of your ICD above the shoulder. Movement of the large shoulder muscle could cause the lead inside of the heart to move out of position. Repositioning of the leads will require a surgical procedure

Do not participate in any activities that require forceful large arm movements, such as basketball, swimming, golf, and vacuuming

Do not lift anything over 10 pounds

We recommend walking for at least 30 minutes, five days a week. You may increase your activities slowly and resume your usual level of activity after 6 weeks

If you have additional questions about activities and exercise, please discuss them with your Stanford care team

Driving should be discussed on an individual basis with your doctor.

Cover the ICD site if in direct sunlight as the metal of the ICD will warm beneath the skin.

Magnetic Interference

Electromagnetic fields can interfere with the ICD’s ability to sense an abnormal rhythm. Some devices and machines are safe to use while other devices are not:

Avoid devices or areas that have strong electric or magnetic fields such as: leaning over a car engine while it is running, running motorcycle engines, power plants, ham radios, etc.

Cellular phones, MP3 players, and headphones should be held at least 6 inches away from your ICD. Hold the phone on the ear opposite your ICD and avoid keeping your phone and headphones in a pocket on top of your ICD. Avoid resting your head on the chest of a person with an ICD while wearing headphones.

When traveling in the airport, tell security you have an ICD and request for a hand search instead of walking through the metal detector. The metal detector will not harm the ICD but it may set off the alarm. Limit scanning with a hand-held metal detector over the device no longer than necessary.

Inform your health care provider, such as your dentist, that you have an ICD before they perform any test or procedure using medical or electronic devices:

If you are to undergo dental procedures or any type of surgery involving electrocautery, have your dentist/doctor contact either the device manufacturer or Cardiac Arrhythmia Service. The electrocautery might be misinterpreted by the ICD as an arrhythmia and deliver a shock or therapy that you do not need.

Normal teeth cleaning are safe and require no special instructions.

Important: You cannot have an MRI done because of the possible magnetic interference.

Identification

Carry your ICD identification card in your wallet at all times. You will be given a temporary card upon discharge. A permanent card will be mailed to you from the ICD manufacturer in 6-8 weeks.

We suggest that you wear a Medic Alert Emblem. Please ask for the form if you have not been given one.

Please notify your ICD manufacturer if you have a new address or telephone number. Their toll-free phone number is on the temporary and permanent identification card.

Symptoms

If you feel any of the following symptoms, you should lie down immediately, make sure you are in a safe environment, away from any machines or moving vehicles, and call a friend or family member, or call 911:

Lightheadedness

Fast heart rate (palpitations)

Dizziness

Chest pain

Shortness of breath

Fainting or near fainting (syncope)

What To Do If Your Feel a Shock

Call 911 immediately for the following:

If you receive 1-2 shock but you still do not feel well

If you receive 3 or more shocks in rapid succession

If you receive a shock but become or remain unconscious, bystanders should call 911 and immediately start CPR

Call the Stanford Arrhythmia Service at (650) 723-7111 for the following:

If you receive 1-2 shocks and feel that your heart rhythm is back to normal. This is not an emergency if you feel okay but it is important to inform us immediately after the shock

If you did not have any symptoms of an arrhythmia but received a shock, we will set up an appointment to confirm appropriateness of your ICD therapy

If you receive a shock from the ICD while in contact with another person, it will not harm them

Discuss a plan with your family members and friends on what should be done if you receive a shock from your ICD (also called a “shock plan”)

It is advisable that family members be certified in CPR. Classes are available at local chapters of the American Heart Association or the Red Cross.

Follow-Up

At discharge, you will be given a clinic appointment for a wound check at Stanford within 10 to 14 days after implant. Please contact the Stanford Device Clinic at (650) 723-6459 if an appointment for a wound check prior to discharge has not been arranged for you.

It is very important that you have your ICD checked regularly (4 to 6 weeks after implant and every 3 to 4 months thereafter).

It is recommended that you know your ICD parameters. We will give you a copy of your ICD parameters and answer any questions that you may have regarding your device programming upon discharge or during your first clinic visit for a wound check or device check.

Some devices are equipped with Remote Monitoring capabilities where you can send information about your ICD from home that the clinic can view. We recommend that you have this capability for your routine device surveillance. We will discuss with you at your clinic visit.

The device clinic will hold a quarterly patient education seminar regarding general information about ICDs. We will give you the opportunity to ask specific questions regarding your device and to interact with other patients with ICD. Please ask us for the seminar schedule.

Our Clinics

Our nationally recognized electrophysiologists provide exceptional care with compassion for people with all types of arrhythmia. Our team includes experts from several heart specialties with decades of experience in patient-centered care.

Implantable Cardioverter-Defibrillators (ICD)Our highly trained electrophysiologists have years of experience in using implantable cardioverter-defibrillators (ICDs) to treat people with arrhythmias.ICDdefibrillatorimplantable cardioverter-defibrillatorarrhythmiaventriculartachycardiafibrillationsubcutaneous